Lost Receipt Verification Form by pbn10852


									                         Lost Receipt Verification Form
This form is to be used when a receipt or invoice has been misplaced, destroyed or is not
available. Complete all necessary information and submit form with Department
Purchase Requisition or Procurement Card Log. Call the Purchasing Office if you have
any problems completing the form. You will need to submit one form for each receipt or
invoice that you are replacing.

Vendor: _____________________________________ Date of Transaction: __________

Items Purchased                                               Qty         Price        Total

                                                        Total Amount ________________

Method of Payment (check one): Cash ___ Check ___ Credit Card ___
Provide a copy of the check or credit card statement if either of these options is checked.

Reason for no receipt:

Attempted to get reprint of receipt from vendor (check one): Yes ___ No ___
Contact Name(s):
Phone Number:
Reason vendor couldn’t provide reprint:

If no attempt was made to get a reprint please explain why:

I certify that the above expenditure was made on behalf of Pittsburg State University and
is for official use of the State of Kansas.

_________________________________________________                            ___________
     Signature of individual that made purchase                                  Date

_________________________________________________                            ___________
             Department or Area Head                                             Date

Revised 9/4/02

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